cambodia1. 2 cambodia assessment ung phirun chroeng sokhan
TRANSCRIPT
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Cambodia 1
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Cambodia 2
Cambodia Assessment
Ung PhirunChroeng Sokhan
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Cambodia 3
Demographics Cambodia
Area (sq km) 181,000
Population
11,800,000
15.6% urban
GNP per capita US $260
Human Development Index
.514
137/174
Literacy rate
Male: 58.6%
Female: 21.1%
Infant mortality rate 100.2 per 1,000
Life expectancy 54 years
World Bank, 1999
Cambodia
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Cambodia 4
Health Care Delivery System• Public sector: centralized three-tiered health
care system
• NGOs: 108 working in the health sector
• Private: 382 private clinics and hospitals registered
• 70% of providers are not registered
• Household spending on health in 2000 was 11% of GDP, 80% of all health expenditures
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Cambodia 5
Pharmaceutical Sector• Public sector utilizes a centralized procurement
and distribution system
• Donor-funded pilot programs contract out management of public health facilities to private organizations
• Six pharmaceutical manufacturers; only three operating
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Cambodia 6
Pharmaceutical sector• Total pharmaceutical expenditures for 2000 were
31.46 million USD Households: 57% Donors: 25% MOH: 18%
• There are approximately 3700 retail outlets for pharmaceuticals, of which 75% are unlicensed
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Cambodia 7
Geographic Accessibility
65% of the population is less than 10 km or 2 hours’ walk of
basic health care facility
Hou
rs
Average number of facility operating hours per day
12.4 12.4
6.6
0
9.97.7
11.3 11.7
0
4
8
12
16
20
24
Private pharmacy Public NGO clinic Private clinic
Weekdays Weekends
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Cambodia 8
Availability
Public Private clinic
Private pharmacy
NGO
clinic
ODMS
Set of un-expired tracer items in stock
59% 56% 66% 50% 69%
Time out of stock
3% 1% 0% 0% 4%
Prescribed items dispensed
80% 59% NA 54% --
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Cambodia 9
Affordability
NGO/ Mission
Private Facilities
Pharmacy/Drug Depots
Unlicensed Pharmacies
Pneumonia (pediatric 1-5 years)
Amoxicillin 250mg (IMCI)
.26 2.99 .97 1.4
Co-trimoxazole 80/400 (IMCI)
.91 2.89 .75 .84
Dysentery (pediatric 1-5 years)
Co-trimoxazole 80/400 (IMCI)
.91 2.89 .75 .84
Number of days worked to pay for treatment
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Cambodia 10
Affordability (2)• Less than 1% of population is covered by any risk sharing scheme
•Payment for health care services is a major cause of impoverishment; 46% of loss of farms was due to health care costs
•Children from poor families have lower treatment rates than those from higher income families (20% vs. 52%)
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Cambodia 11
Affordability (3)
• Average percentage difference of lowest prices among facilities
– Highly variable, 524% to 1140%
• Median percentage difference between most and least expensive unit price within facilities– 55% to 273%
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Cambodia 12
Acceptability• Distance, cost, and lack of drugs negatively
influence utilization of public health services
• Overall the public sector was used in 20% of all illnesses and injuries
• Retail drug outlets are the first point of contact for 70% of the population
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Cambodia 13
Quality of Products and Services
0
2
4
6
8
10
12
14
16
18
20
Public
NGO
Private
• MOH Cambodian drug market study found overall failure rate of 13.5%
• 50% of drugs are not registered
• Failure rates:– Registered: 5.2%– Unregistered 22.3%Tracer drugs that failed quality testing
Per
cent
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Cambodia 14
Quality of Products and Services (2)
5651
64
0
10
20
30
40
50
60
70
Encounter prescribed antibiotics (PHC and clinics)
Per
cent
MOH NGO Private • In retail drug shops antibiotics were inappropriately recommended 72% of the time (ARI/ no pneumonia)
• 50% actually purchased antibiotics
• Number of drugs per encounter
MOH 2.0 Private 3.8 NGO 2.5
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Cambodia 15
Quality of Products and Services (3)Exit Interviews
0
10
20
30
40
50
60
70
80
90
100
NamePurposeDurationAdditional InfoName & purpose
Simulated Client
0% 20% 40% 60% 80% 100%
Additionalinfo
Instructions
Possibleproblems
Advice onfever
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Cambodia 16
Access Gaps• Availability
• Affordability
• Quality of drug products
• Quality of pharmacy services and information
• Geographic access in rural areas
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Cambodia 17
Potential Strategy• Performance-based network of retail drug
outlets
• Network of health service providers to be served by the pharmacy network
• Group purchasing cooperative for network members
• Community-based care program
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Cambodia 18
Potential Country Strategy (2)Group
purchasing cooperative
Quality
Standards, training, monitoring,
accreditation
Availability Affordability
Consumers
Network of pharmacies, drug depots
Network of providers
InsurersNGOs
working in health
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Cambodia 19
Viability• Facilitating factors
Franchises, as a means of meeting public health needs, have a basis in regulations and public policy
The proposed intervention has strong MOH and private sector support
Proposed pilot locations are willing to dedicate human and financial resources
The intervention will build on existing programs that work with drug retailers
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Cambodia 20
Viability (2)• Barriers
The government supports public-private partnerships, but sometimes exhibits ambivalence about the private sector
Incentives for continued participation are rather limited
Human resource development may require medium- to long-term support to fully develop